Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction

Twenty-one patients with gigantic defects of the scalp and middle third of the face and palate following excision of neglected or recurrent tumors, burns, and infections have undergone microsurgical reconstruction. Wide resection of the middle third of the face, orbit, and palate requires "complex" three-dimensional volume reconstruction, whereas extensive defects of the scalp and skull (exceeding 80 cm2) require coverage of the larger surface area soft-tissue defect and the exposed brain and dura. The latissimus dorsi free-muscle flap and split-thickness skin graft have become our methods of choice for extensive scalp and skull defects. The latissimus dorsi musculocutaneous free flap is preferable for reconstruction of complex palatal and external skin and orbital defects of the middle third of the face. Microsurgical free-tissue transfer reliably frees the oncologic surgeon from the constraints imposed by conventional reconstructive techniques and may therefore allow improved curative or at least palliative resection of these extensive tumors.     

Free-flap reconstruction of large defects of the scalp and calvarium

Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.     

A new composite facial and scalp transplantation model in rats

There are limited sources of autogenous tissue available for reconstruction of severe facial and scalp deformities caused by extensive tumor ablation, burns, or trauma. Allografts from cadaveric sources may serve as a reconstructive alternative. However, technical and immunological aspects of harvesting and transplanting face and scalp flaps limit the routine use of such procedures. For evaluation of the feasibility of composite-tissue reconstruction, an experimental model of composite face/scalp flap transplantation in rats was designed. Technical aspects of the model, survival rates, and the complications encountered during development of the model are presented. A total of 64 animals, in three experimental groups, were studied. In group I, the anatomical study group (n = 6), the anatomical features of the face and scalp region in rats were explored. Groups II and III were the transplantation groups. Isograft transplantations were performed between identical Lewis rats (RT11 to RT11), and allografts were transplanted, across major histocompatibility complex barriers, between Lewis-Brown Norway rats (RT1l/n) and Lewis rats (RT11). In group II (the control group, n = 8), transplantation of nonvascularized composite face/scalp isografts and allografts was performed. In group III (the transplantation group, n = 50), vascularized face/scalp isografts (n = 36) and allografts (n = 14) were transplanted. Complications included partial or total flap necrosis, death attributable to food aspiration, and poor general condition. To prevent acute and chronic allograft rejection, cyclosporine A (16 mg/kg per day) therapy was initiated 24 hours after transplantation; the dose was tapered to 2 mg/kg per day within 4 weeks and was maintained at that level thereafter. Long-term survival (>170 days) was achieved, without any signs of rejection, with low-dose (2 mg/kg per day) cyclosporine A therapy. This is the first report documenting successful composite face/scalp flap transplantation in the rat model.     

Scalp stretching with a tissue expander for closure of scalp defects

The authors show a way of reconstruction of scalp defects with excellent results using a tissue expander. This method creates "new" scalp tissue for coverage of defects with normal hair-bearing skin having a dense and even growth of hair. The hairs grow in the correct direction. The authors also show that almost all of the "new" hair-bearing scalp gained by the tissue expander is a result of stretching the scalp over the expander and its close surroundings and that only a very minute portion is gained by migration of the scalp from farther away.     

Cicatricial eyebrow reconstruction with a dense-packing one- to two-hair grafting technique

Scarring eyebrow loss is usually repaired with a hair-bearing island scalp flap or scalp strip grafting technique. The results, however, are usually not desirable with regard to appearance. In this article, a one- or two-hair graft with a dense-packing technique was developed for cicatricial eyebrow reconstruction. It was carried out by harvesting a scalp strip close to the hairline of the back, then dividing it into a series of one- or two-hair grafts, and finally implanting the grafts into the prepared recipient holes of the eyebrow with a desired hair direction. With the authors' experience in treating 96 patients (154 eyebrows) in cases of burn, skin grafting, traumatic scarring, and chemical peeling scar after tattoo removal, the eyebrows could be restored in only one session. In general, 150 to 200 grafts with 200 to 250 hairs were needed for a complete male eyebrow reconstruction and 100 to 150 grafts with 150 to 200 hairs were needed for a complete female eyebrow reconstruction. The maximal hair density was 91.5 hairs/cm per session. Over a 6-month follow-up period, the mean graft survival rate reached 98.1 percent. All of the patients achieved satisfactory results, with a very natural appearance. These results indicate that the above-mentioned technique could be a practical, effective, and probably ideal method for cicatricial eyebrow reconstruction.     

Treatment of burn alopecia with tissue expanders in children

During the past 18 months, 60 tissue expanders were utilized in the reconstruction of 42 children with burn alopecia of the scalp not amenable to a single excision and primary closure at the Shriners Burns Institute in Galveston, Texas. The children were grouped according to the degree of alopecia. All patients with defects of 15 percent or less of the total hair-bearing scalp were able to obtain complete closure of their defects with two operations, i.e., one to place the expander and the second to remove the expander and advance the flaps. Some patients with defects up to 40 percent were closed with serial expansion. Patients with even larger defects had a significant reduction in the percentage of alopecia and benefited from re-creation of anterior hairlines. We have encountered a postoperative complication rate of 10 percent. When compared to previous methods of treating burn alopecia, tissue expansion allows a more rapid closure, fewer operations and coincident anesthetics, and decreased total length of hospitalization.     

Island scalp flap for superior forehead reconstruction

An island scalp fasciocutaneous flap, based on the posterior superficial temporal vessels, is described for single-stage reconstruction of full-thickness forehead and scalp defects. The hairline can be precisely determined and tailored to restore symmetry. By removing the hair-bearing dermis of the forehead portion of the flap and placing a full-thickness skin graft, aesthetic reconstitution of the forehead skin is achieved. This flap is especially useful when exposed calvarium limits other techniques.     

Congenital scalp and calvarial deficiencies: principles for classification and surgical management

Congenital defects of the scalp and skull present a challenge for care providers because of a combination of their rarity and the magnitude of potential morbidity. Recent advancements in autogenous and alloplastic cranioplasty and scalp reconstruction techniques argue for a comprehensive consideration of this problem. This article (1) reviews the causes of congenital scalp and calvarial defects; (2) proposes a classification system based on defect type, similar to the tumor-node-metastasis classification, in that defect location, defect size, and extent of neuromeningeal involvement are the critical variables; and (3) presents algorithms for care based on the defect classification. A set of management principles on which treatment plans can be based for these unique problems is provided.     

Use of the temporary soft-tissue expander in posttraumatic alopecia

Use of temporary soft-tissue expansion in five patients with posttraumatic alopecia and one patient with congenital alopecia is presented. Indications, operative technique, results, and complications are discussed. It is recommended that transpositional and free scalp flaps be expanded prior to transfer, and it is shown that to achieve greater expansion secondarily, the expanders can be reinserted and the scalp reexpanded as needed. The expansion technique provides a quantity of tissue of similar color, texture, and hair-bearing qualities for reconstruction of adjacent defects and makes secondary reconstruction of donor sites unnecessary. After a minimum follow-up of at least 1 year in each case presented, we have determined that the method is safe, simple, and reliable and provides excellent aesthetic results and high patient acceptance and satisfaction.     

The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp

Hair transplantation by use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) used in large numbers (>1000 grafts) in a single session was initially described for the treatment of male pattern baldness. More recently, the author has found many other applications, particularly in facial and scalp reconstruction. The most common causes for aesthetic hair restoration of those areas in the author's experience include hair loss resulting from aesthetic facial rejuvenation surgery, revision of unsatisfactory results from previous hair transplantation, burn alopecia, congenital reasons, and hair loss after oncologic resections. The basic technique is described in detail, with variations given for each of the challenging anatomic areas, including the sideburns and temporal hairline, eyebrows, eyelashes, mustache, beard, and remaining scalp. Special attention is given to the direction of hair growth, hair texture, aesthetic planning, and absence of detectable scars, in order to mimic nature and to result in a minimal number of procedures. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp has been found to be safe and predictable, and has provided a high level of patient satisfaction.     

Sideburn reconstruction with an arterial V-Y hair-bearing scalp flap after the excision of basal cell carcinoma

A new flap is presented for sideburn reconstruction. It has good vascularity and hair direction. There is some tension in the closure of the scalp donor site that can be associated with alopecia. The flap should be advanced only to the desired sideburn level, with a cervicofacial flap covering any remaining defect. Follow-up at 2 years 4 months confirmed the satisfactory result. This flap adds another option to those discussed in this article for sideburn reconstruction.     

The versatile temporoparietal fascial flap: adaptability to a variety of composite defects

The unique properties of the temporoparietal fascial flap (TPFF) offer adaptability in reconstruction of a variety of composite defects. The broad, thin sheet of vascularized tissue may be transferred alone or as a carrier of subjacent bone or overlying skin and scalp. As a pedicled flap, it is ideal for defects of the orbital, malar, mandibular, and mastoid regions. As a free-tissue transfer, the large vessels and lack of bulk find broad utility in reconstruction of the extremities. This flap is our choice for reconstruction of the dorsal hand and non-weight-bearing surfaces of the foot. A viscous gliding surface decreases friction for tendon excursion. The thin contour is aesthetically superior to thicker flaps, allowing unmodified footwear or gloves. The pliable fascia convolutes into surface defects (e.g., bone craters) or drapes over skeletal frameworks (e.g., ear cartilage). The rich capillary network offers nutrition to saucerized bone, cartilage or tendon grafts, and overlying skin grafts. The geometry of the skull lends to fabrication of membranous bone for complex facial puzzles. The donor site is well disguised by hair growth. Twelve cases performed over a 2-year period demonstrate the versatility of this flap. These include complex foot reconstruction, ear and scalp avulsion, shotgun wound of the cheek and orbit, posttraumatic jaw recontouring, chronic osteomyelitis of the hand and foot, and acute resurfacing of dorsal hand with tendon reconstruction.     

Microsurgical scalp reconstruction in the patient with cancer

The literature regarding reconstruction of large scalp wounds with free tissue transfer consists mostly of case reports and small series, and none of the published reports focus on the particular problems of the oncology patient. Here the authors describe their experience with 37 flaps in 32 patients, all of whom required scalp reconstruction with free tissue transfer after tumor extirpation. Twenty-seven free flaps were performed at the time of the initial surgery and 10 were performed after a prior reconstruction failed. The authors describe the characteristics of the patients and procedures, including tumor type, wound size and complexity, flaps and recipient vessels used, preoperative and postoperative radiation therapy, and complications. Most (72 percent) of the tumors were recurrent or persistent. The free tissue transfer was successful in all patients. There was a 59 percent overall complication rate with 32 percent of patients requiring a secondary surgical procedure. Most of the complications were wound-healing complications. Although there were two cases of vein thrombosis, these were salvaged by revision, and no flaps were lost. Nine patients underwent postoperative radiation therapy that was well tolerated. Only four patients underwent cranioplasty at the time of the initial operation, and no secondary cranial reconstructions were performed. The authors conclude that preoperative and postoperative radiation therapies as well as the need for expedient tumor resection and immediate flap coverage are issues that make free tissue transfer attractive for the oncology patient who needs scalp reconstruction. Although the complication rate is relatively high and a significant percentage of patients require a secondary procedure, free flap coverage was efficacious for all patients in this group. Cranioplasty is not usually required but, if needed, alloplastic or autologous cranial reconstruction does not appreciably increase morbidity in the selected patient.     

Scalp reconstruction with a prefabricated abdominal flap carried by the radial artery.

Custom prefabrication of free flaps provides an unlimited variety of applications, since flaps can be created with expendable tissues and without restriction to naturally occurring vascular territories. These principles also can be used to customize flaps that could not be completed by conventional means. We report a case of scalp reconstruction using a random-pattern abdominal flap in which a radial artery fascial flap was induced to serve as the vascular carrier. In addition to providing durable scalp coverage, the prefabricated free flap enabled salvage of an abdominal flap that would otherwise have been aborted after intermediate transfer to the forearm.     

A lengthened omental pedicle in facial reconstruction

The omentum continues to be a versatile reconstructive tool with increasing application, but its use for defects of the face or scalp has previously been limited to microvascular transfer. This case demonstrates the feasibility of using the omentum for facial reconstruction where microvascular techniques may not be suitable or available, thus making the omentum an even more valuable tool than we had previously appreciated.     

Hair transplantation in alopecia due to radiation

Two cases of alopecia due to radiation of the scalp are presented in which it has been possible to achieve a technically and cosmetically satisfactory reconstruction by punch hair grafting. This does not mean that every case is suitable, but it does mean that those without contraindications should at least be given a try.     

Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses

Six cases of large defects of the scalp, skull, and dura following tumor ablation and radiation are presented. Each was accompanied by chronic infection in the irradiated defect. Efforts to reconstruct the resulting defects with local flaps were not successful. One-stage reconstruction was then accomplished in each case utilizing a latissimus dorsi musculocutaneous or myo-osteocutaneous free flap transferred by microvascular anastomoses. The versatility of the latissimus dorsi musculocutaneous and/or osseous flap allows single-stage reconstruction of these complex defects.     

Concentration of Zinc,Copper, Iron,Calcium, and Magnesium in the Serum,Tissues, and Urine of Streptozotocin-Induced Mild Diabetic Rat Model

A survey carried out in Lake Tana in 2015 found that Hg levels in some fish species exceeded internationally accepted safe levels for fish consumption. The current study assesses human exposure to Hg through fish consumption around the Lake Tana. Of particular interest was that a dietary intake of fishes is currently a health risk for Bihar Dar residents and anglers. Hair samples were collected from three different groups: anglers, college students and teachers, and daily laborers. A questionary includes gender, age, weight, activity. Frequency of fish consumption and origin of the eaten fish were completed by each participant. Mercury concentrations in hair were significantly higher (P value <0.05) for anglers (mean?±?standard deviation 0.120?±?0.199 μg/g) than college students (mean?±?standard deviation 0.018?±?0.039 μg/g) or daily workers (mean?±?standard deviation 16?±?9.5 ng/g). Anglers consumed fish more often than daily workers and college group. Moreover, there was also a strong correlation (P value <0.05) between the logarithms of total mercury and age associated with mercury concentration in scalp hair. Mercury concentrations in the hair of men were on average twice the value of the women. Also, users of skin lightening soap on a daily basis had 2.5 times greater mercury in scalp hair than non-users. Despite the different sources of mercury exposure mentioned above, the mercury concentrations of the scalp hair of participants of this study were below levels deemed to pose a threat to health.     

Outcome of scalp donor sites in 450 consecutive pediatric burn patients

The scalp is a useful and reliable donor site in pediatric burn patients that can be multiply harvested with minimal morbidity. Healing complications, however, may include alopecia and chronic folliculitis. To investigate scalp donor-site morbidity, a consecutive series of 2478 pediatric burn patients treated over a 10-year period were reviewed. A total of 450 of these patients had scalp donor sites for wound closure. Percent of total body surface area burned was 46+/-23 percent (mean+/-standard deviation), and the mean number of sequential scalp donor-site harvests was 2.2+/-2 (range, 1 to 10) with mean intervals between harvesting of 6+/-0.6 days. Ten patients (2.2 percent) had related complications. Eight patients developed scalp folliculitis, with Staphylococcus sp as the predominant organism (80 percent). Two patients were managed successfully with wound care alone; the other six patients required surgical debridement and split-thickness skin grafting to achieve wound healing. These eight patients developed varying degrees of alopecia. Two patients developed alopecia without previous folliculitis. Six patients required reconstructive surgery, which consisted of primary closure (3), staged excision (1), and tissue expansion (2). A number of variables were examined to determine any differences in the group that had complications compared with the group of patients that did not. No differences in age, sex, race, burn type, burn size, septic episodes, time to wound closure, or number of times the scalp was harvested were detected. Healed second-degree burns to the scalp that were subsequently taken as donor sites seemed to be a risk factor (p < 0.05) for folliculitis and alopecia. Our study confirms that scalp donor sites are reliable with low morbidity. Complications include alopecia and chronic folliculitis that can be avoided by meticulous technique and avoidance of previously burned areas.     

Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps

A composite flap is presented based on the latissimus dorsi myocutaneous unit together with the underlying ninth to eleventh ribs. Three patients are presented. In two, a full-thickness chest-wall defect was present. In one, a full-thickness scalp and cranial defect was present. Use of the composite osteomyocutaneous latissimus dorsi free flap as a pedicled flap in two patients and as a free flap in one patient resulted in successful definitive reconstruction in all with no complications. This procedure necessitates no transplantation of soft tissue prior to bone grafting to maintain local vascularity, so the simultaneous one-stage reconstruction of an osseous-soft-tissue defect becomes possible easily.